Scope

Disease/Condition(s)

Mild traumatic brain injury (MTBI)

Note:

Mild traumatic brain injury is defined as an acute alteration in brain function caused by a blunt external force and is characterized by a Glasgow Coma Scale (GCS) score of 13 to 15, loss of consciousness for 30 minutes or less, and duration of posttraumatic amnesia of 24 hours or less. The terms mild traumatic brain injury and concussion may be used interchangeably.

A comprehensive review of the management of concussion in athletes is beyond the scope of this practice management guideline (PMG).

Anticoagulated patients with supratherapeutic INR values should be admitted for observation

Timing of return to activities:

Resolution of measurable deficits in cognition and memory is usually 1 month

Resumption of driving motor vehicle is individualized

Return to work is individualized

Note: Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.

Methodology

Hand-searches of Published Literature (Primary Sources)Hand-searches of Published Literature (Secondary Sources)Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

A search of PubMed and Cochrane Library databases was performed. Key words included closed head injury, concussion, and traumatic brain injury and included descriptors such as mild and minor. Additional references were obtained in the reference sections of retrieved articles, from review articles, and from Web resources. English-language references from 1980 to 2011 were examined, and articles published after 1999 were emphasized. A significant number of studies that were noncontributory were excluded. There was a notable lack of randomized, controlled trials, and it was not possible to restrict our review of any mild traumatic brain injury (MTBI) subtopic to such trials.

Number of Source Documents

A total of 112 articles were reviewed.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Class I: Prospective randomized clinical trials.

Class II: Clinical studies in which data were collected prospectively or retrospective analyses based on clearly reliable data.

Class III: Studies based on retrospectively collected data.

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Recommendations were characterized as Level 1, 2, or 3 in the same fashion as in other Eastern Association for the Surgery of Trauma (EAST) guidelines (see the "Rating Scheme for the Strength of the Recommendations" field).

Rating Scheme for the Strength of the Recommendations

Level 1: The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data, however, strong Class II evidence may form the basis for a Level I recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a Level I recommendation.

Level 2: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level 3: The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

All authors participated in critical revision and approved the final version.

Recommendations

Major Recommendations

The levels of recommendation (1-3) and classification of evidence (I-III) are defined at the end of the "Major Recommendations" field.

Note: Some recommendations from the 2001 Eastern Association for the Surgery of Trauma (EAST) mild traumatic brain injury (MTBI) guidelines are essentially unchanged in this update. However, a number of alterations and additions have been made. The previous admonition to obtain a brain computed tomographic (CT) scan in all patients with suspected brain injury has been modified to reflect the use of standardized criteria (such as the Canadian CT Head Rule [CCHR]) in some centers to identify patients that require a CT scan. The indications for emergency department (ED) discharge of patients with MTBI were examined in a number of high-volume studies since 2001, and our recommendation was changed to Level II to reflect this. Two specific recommendations on anticoagulated patients with MTBI were added.

Level 1

There are no level 1 recommendations.

Level 2

Clinicians should perform brain CT scan on patients that present with suspected brain injury in the acute setting if it is available.

If CT resources are limited, consideration may be given to the use of a set of standardized criteria (e.g., the Canadian CT Head Rule [CCHR], New Orleans Criteria [NOC]) to determine which patients with MTBI receive a brain CT scan. Clinicians should be aware that this practice is associated with a nonzero missed injury rate.

Level 3

Clinicians should not routinely use magnetic resonance imaging (MRI), positron emission tomography, or nuclear magnetic resonance in the clinical management of patients with MTBI at the present time (Level 3).

Patients with an isolated MTBI and a negative brain CT scan result may be discharged from the ED if they have no other injuries or issues requiring hospital admission (Level 2).

Patients taking warfarin who present in the acute setting with an MTBI should have their international normalized ratio (INR) level determined. (Level 3).

Anticoagulated patients with supratherapeutic INR values and a normal initial brain CT scan result remain at significant risk for interval development of intracranial hemorrhage and should be admitted for a period of observation (Level 3).

Patients may be advised that measurable deficits in cognition and memory usually resolve at 1 month but that in 20% to 40% of cases, postconcussive symptoms may persist for 3 months or longer (Level 3).

The ability to safely operate a motor vehicle may be impaired for a variable length of time in patients with MTBI. The timing of resumption of driving should be individualized (Level 3).

The timing of returning to work for patients with MTBI should be individualized. Formal neuropsychologic testing can be considered in some cases (Level 3).

Biochemical markers such as S-100, neuron-specific enolase, and serum tau should not be routinely used in the clinical management of patients with MTBI except in the context of a research protocol (Level 3).

Definitions:

Classes of Evidence

Class I: Prospective, randomized clinical trials

Class II: Clinical studies in which data were collected prospectively or retrospective analyses based on clearly reliable data

Class III: Studies based on retrospectively collected data

Levels of Recommendation

Level 1: This recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data, however, strong Class II evidence may form the basis for a Level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a Level 1 recommendation.

Level 2: This recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level 3: The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

Benefits/Harms of Implementing the Guideline Recommendations

The practice of obtaining a brain computed tomography (CT) scan for every patient that could conceivably have positive findings leads to a significant number of negative study findings and may also be burdensome from a financial and resource standpoint.

Efforts to achieve an overall reduction on CT use will inevitably lead to a higher missed injury rate, although whether these injuries are clinically significant is debatable.

Contraindications

Contraindications

Patients with a minor traumatic brain injury who are therapeutically anticoagulated (e.g., with warfarin, clopidogrel, or other agents) may warrant special consideration.

Trauma patients in general have a significant incidence of individual symptoms that overlap with postconcussive syndrome (PCS), especially those with posttraumatic stress disorder. It has been noted that the high incidence of posttraumatic stress disorder in combat veterans is a significant confounding factor in terms of determining if reported symptoms are truly caused by the blunt head injury itself.

Qualifying Statements

Qualifying Statements

The natural history of mild traumatic brain injury (MTBI) is poorly understood in part because the studies conducted thus far vary widely in their inclusion criteria, methodology, and outcome variables measured. The studies tend to be scattered across a wide variety of journals in a number of disciplines and originate in many different countries. As a result, there has been an accumulation of a large number of studies in which each uses a different measurement tool to describe a set of different outcome variables in its own unique study population.

The epidemiology of MTBI remains poorly understood in part owing to inconsistent definitions and terminology. These factors make it difficult to determine exactly what percentage of all patients with traumatic brain injury (TBI) have an MTBI.

The Eastern Association for the Surgery of Trauma (EAST) is a multi-disciplinary professional society committed to improving the care of injured patients. The Ad hoc Committee for Practice Management Guideline Development of EAST develops and disseminates evidence-based information to increase the scientific knowledge needed to enhance patient and clinical decision-making, improve health care quality, and promote efficiency in the organization of public and private systems of health care delivery. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors' personal observations and do not imply endorsement by nor official policy of the Eastern Association for the Surgery of Trauma.

"Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."* These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in a given guideline. Guidelines are not entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results. While guidelines can be written that take into account variations in clinical settings, resources, or common patient characteristics, they cannot address the unique needs of each patient nor the combination of resources available to a particular community or health care professional or provider. Deviations from clinical practice guidelines may be justified by individual circumstances. Thus, guidelines must be applied based on individual patient needs using professional judgment.

Pediatric concussions - Podcast #21. 2012. Available from the EAST Web site.

Adult concussions - Podcast #22. 2012. Available from the EAST Web site.

Also, continuing medical education (CME) credit on pediatric and adult concussion is available from the EAST Web site.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on September 17, 2001. The information was verified by the guideline developer on September 27, 2001. This NGC summary was updated by ECRI Institute on May 7, 2013.

Copyright Statement

This NGC summary is based on the original guideline which is copyrighted by the Eastern Association for the Surgery of Trauma (EAST).

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